Request an Appointment with The Ear Institute - Diagnostic Audiology and Balance Testing

By taking a few minutes to complete this form, you -- or your representative acting on your behalf -- can request an appointment with the Ear Institute at New York Eye and Ear Infirmary of Mount Sinai. Once your form is submitted, you should expect a response from our staff within 48 hours (Monday through Friday.).

This form is not for emergency services. For emergency medical treatment or medical advice concerning specific conditions or treatments, please consult with a qualified health care provider or go to your nearest Hospital Emergency Room.

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If you would prefer to make an appointment by phone, please call the Center for Hearing and Balance Disorders at The Ear Institute directly at (212) 979-4340.

 
The Ear Institute Appointment Request Form - Diagnostic Audiology and Balance Testing

Patient Information * indicates a required field

* Title   

* Patient's First Name   

Patient's Middle Initial   

*Patient's Last Name   

*Patient's Address   

*City   

*State or Province   

*ZIP or Postal Code   

*Telephone  

Call me at this number first 

Other Telephone  

Call me at this number first 

Best time to call   

Email Address 

*Patient's Date of Birth  

dd/mm/yyyy

*Patient's Sex  

Male Female

*Have you been a  
patient at NYEE before?  

Yes No
If you answer YES, please provide your Medical Record Number below (if you have it)

Reason for Visit   

Medical Record #   

7 digits, no spaces or dashes

Contact Information

Please provide the following information if different from above. This person will be the primary contact for the appointment request.

Relationship to Patient   

Title   

 First Name   

Middle Initial   

Last Name   

Address   

City   

State or Province   

ZIP or Postal Code   

Telephone   

Call me at this number first

Other Telephone     

Call me at this number first 

Optional Information

How did you find   
our website?   

Infirmary Phone "Hold" Message
Knew web address
Search Engine
Link from another website
Friend/Word of Mouth
Advertisement
I've been a patient at NYEE before
Other (please specify)

Contact Us

Center for Hearing & Balance Disorders
at The Ear Institute

New York Eye and Ear Infirmary of Mount Sinai
230 Second Avenue, 2nd Floor
(at 14th Street)
New York, NY  10003
(212) 979-4340 Main Number
(212) 533-3489 FAX

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